Position Statement: Botulinum Toxin Treatment

Position Statement: Botulinum Toxin Treatment

Section I. Treatment of Spasmodic Dysphonia (Laryngeal Dystonia)

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. ("AAO-HNS") considers Botulinum toxin a safe and effective modality for the treatment of spasmodic dysphonia and it may be offered as primary therapy for this disorder.

Section II. Botox Treatment for Other Head And Neck Dystonias

A. Blepharospasm

The AAO-HNS considers botulinum toxin a safe and effective modality for the treatment of blepharospasm and it may be offered as a primary form of therapy. Botulinum toxin has been approved as a safe and effective treatment of blepharospasm by the FDA.

B. Cervical Dystonia (Spasmodic Torticollis)

The AAO-HNS considers botulinum toxin a safe and effective modality for the treatment of cervical dystonia. There is some controversy as to whether botulinum toxin or pharmacotherapy should be offered as primary therapy. The benefit from botulinum toxin outweighs that of pharmacotherapy in many cases, certainly for the treatment of rotational cervical dystonia, or cervical dystonia associated with severe pain. In cases where there is inadequate response with pharmacotherapy, or there are intervening side effects, treatment with botulinum toxin may be offered.

C. Orolinguomandibular Dystonia

  • The AAO-HNS states that local injections of botulinum toxin into the masseter and temporalis muscles for jaw-closing, and  pterygoid and digastic muscles for jaw-opening dystonia is established as a safe and effective modality for managing this disorder.
  • Considering the difficulty of the procedure in treating complicated jaw deviations and jaw opening, this form of treatment is limited to patients who have failed more conservative therapies. However, the benefit has been dramatic for some in this select group. Use of botulinum toxin for jaw-opening and deviation dystonia, injecting toxin into the pterygoid and digrastic muscles is promising, but additional experience is needed.
  • Lingual dystonia may be effectively treated with botulinum toxin, but there is a significant risk of dysphagia. Botulinum toxin therapy is investigational for this indication.

D. Hemifacial Spasm (HFS) and/or Synkinesis

The AAO-HNS considers local injections of botulinum toxin into facial muscles a safe and effective modality in treating hemifacial spasm and/or synkinesis. This modality of therapy may be offered as primary therapy in managing the condition. Botulinum toxin can be particularly helpful in treating synkinesis to reestablish facial symmetry following a facial nerve paralysis. 

E. Neurogenic Laryngeal Stridor

The AAO-HNS considers local injections of botulinum toxin into laryngeal muscles an effective modality in treating neurogenic laryngeal stridor. This modality of therapy may be offered as primary therapy in managing the condition. While it is generally very safe, the nature of the disorder and the potential contributing problems such as stridor and aspiration should be considered in its case.

F. Frye's Syndrome

Botulinum toxin can be applied to patients for treatment of Frye's Syndrome and gustatory sweating related to autonomic dysfunction.

Section III.  Treatment of Other Conditions

Facial Dynamic Rhytids

Botulinum toxin can be applied to patients for the treatment of dynamic and hyperkinetic facial lines and furrows.

Recalcitrant Hyperfuntional Voice Disorders

Botulinum toxin can be injected for management of recalcitrant muscular tension dysphonia, mutational dysphonia, and other hyperfunctional voice disorders (i.e., vocal fold granulomas or traumatic mucosal injury) that do not resolve with more traditional voice therapy methods and other more conservative medical measures.

Cricoppharyngeus Muscle Hypertonicity

In select patients, botulinum toxin may be useful in the treatment of dysphagia due to hypertonicity of the cricopharyngeus muscle. Botulinum toxin can also be applied to patients with post-laryngectomy cricopharyngeus muscle hypertonicity causing difficulty with the use of voice prostheses. 

Adopted 7/20/1990
Reviewed 9/20/1995
Revised 4/9/1997
Reaffirmed 3/1/1998
Reviewed 1/3/2006
Revised 12/8/2012

Important Disclaimer Notice (Updated 7/31/14)

Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery, Inc. or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.